1. Determinants of Health: Income Inequality and Mental Health 8/28/20141 E. Jane Costello William E. Copeland Adrian Angold Center for Developmental Epidemiology Duke University

2. Poverty is not good for children’s present or future mental health. Is this true? If so, Why?  Reduced access to treatment  Reduced access to material resources  Poor children have worse parenting Does poverty cause problems or do problems cause poverty? (social causation vs. social selection) 8/28/20142

3. Poverty is not good for children’s present or future mental health. 3-month prevalence of one or more DSM-IV psychiatric disorders in poor/non-poor* children (poverty= low SES) 2 out of 3 of 1) Household is below the federal poverty line; 2) low parental occupational level; 3) parental education less than highschool graduation 8/28/20143

4. Poverty is not good for children’s present or future mental health. 3-month prevalence of one or more DSM-IV psychiatric disorders in poor/non-poor* children (poverty= material hardship) *Material hardship: No health insurance, Poor financial coverage, Residential instability, No health or MH insurance 8/28/20144

5. Poverty is not good for children’s present or future mental health. Why not?  Reduced access to treatment  Reduced access to resources  Poor children have worse parenting 8/28/20145

6. Reasons: 1. Reduced access to treatment? 3-month use of specialty mental health services by poor/non-poor* children with one or more DSM-IV psychiatric disorders in(poverty= material hardship) *Material hardship: No health insurance, Poor financial coverage, Residential instability, No health or MH insurance 8/28/20146 Children living in poverty had GREATER access To specialty mental health care than non-poor children

7. Reduced access to treatment? Poor children had better access to services than non-poor children with a psychiatric disorder. 8/28/20147

8. Reasons: 1. Reduced access to treatment? 3-month use of specialty mental health services by children with one or more DSM-IV psychiatric disorders by type of insurance 8/28/20148

9. Reduced access to treatment? Adolescents with public insurance (Medicaid, SCHIP, IHS) had better access to specialty MH care than adolescents with private insurance 8/28/20149

10. Poverty is not good for children’s present or future mental health. Why not?  Reduced access to treatment  Reduced access to resources  Poor children have worse parenting 8/28/201410

11. Impact of material hardship and poverty on rates of psychiatric disorder, age 9-16 8/28/201411

12. Impact of material hardship and poverty on rates of psychiatric disorder, age 9-16  Poverty has a greater impact than specific types of material hardship at this age 8/28/201412

13. Poverty is not good for children’s present or future mental health. Why not?  Reduced access to treatment  Reduced access to resources  Poor children have worse parenting 8/28/201413

14. Poor children have worse parenting % with one or more DSM-IV psychiatric disorders in children with varying degrees of family stressors, (poverty= material hardship) *Material hardship: No health insurance, Poor financial coverage, Residential instability, No health or MH insurance 8/28/201414

15. Poor children have worse parenting Interaction: the worse the parenting the more at risk poor children are relative to non-poor children 8/28/201415

16. Can changing family resources change children’s mental health? Hard to be sure because of the chicken and egg problem: – Does poverty cause child mental illness or does children’s mental illness cause poverty? 8/28/201416

17. 4/25/201217

18. Number of Cherokee families that moved out of poverty, 1996-2000 Ex-poor: 14.4% Persistently poor: 53.2% Never poor: 32.4% 4/25/201218

19. Impact of casino opening on children’s behavioral symptoms; American Indians 4/25/201219

20. Impact of increased income on children’s psychiatric symptoms; Anglo and Indian children 4/25/201220

21. Impact of increased income on children’s psychiatric symptoms; Anglo and Indian children 4/25/201221

22. 4/25/201222 Estimation of Reduction in Total Societal and Individual Costs by Categories per Individual

23. 4/25/201223

24. Take-home message Universal (primary) prevention gets over the access-to-care barrier Universal prevention avoids “labeling” Reducing poverty has a long-term effect on children’s mental health problems A universal intervention can have effects beyond the targeted area 8/28/201424

25. Thank you